Liberty CAD Check By Fax Authorization Form

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Please print and complete this form.  You must complete the ENTIRE FORM or your order will not be processed.  You will need to tape or paste a check in the box below.  Please fill out the check like you normally would, payable to "Liberty CAD", but be sure not to cover any numbers or codes on the check.  Fill out and sign the authorization section below, and fax the ENTIRE FORM and filled out check to (307) 635-3667.  If you have any questions, please call (307) 635-6135.  Thank you!

(Please Fill Out Information Below)

US FUNDS Drawn on US BANK ONLY

Payment Item Details
Liberty CAD Invoice Number:	___________________________________________________
Liberty CAD Invoice Amount:	___________________________________________________
Liberty CAD Invoice Date:	___________________________________________________
Your Companies Purchase Order Number:	___________________________________________________
Other Please Specify:	___________________________________________________
	___________________________________________________

Checking Account Holder Information
First Name & Middle Initial:	___________________________________________________
Last Name:	___________________________________________________
Street Address Line 1:	___________________________________________________
Street Address Line 2:	___________________________________________________
City:	___________________________________________________
State:	___________________________________________________
Country:	___________________________________________________
Zip/Postal Code:	___________________________________________________
Phone Number:	___________________________________________________
Fax Number:	___________________________________________________
E-Mail Address:	___________________________________________________

AUTHORIZATION

I, _________________________________________________ hereby authorize Liberty CAD to withdraw $______________ from my checking account, account information enclosed, one time only, for the purchase of _____________________________________.

The signature below is the authorized signature of the holder of the checking account.

Authorized Signature: ___________________________________________________
Date: ______________________________